Biological agents The principles, design and operation of Containment Level 4 facilities

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1 Health and Safety Executive Biological agents The principles, design and operation of Containment Level 4 facilities Advisory Committee on Dangerous Pathogens

2 Contents PREFACE LIST OF ABBREVIATIONS AIMS OF THIS GUIDANCE SCOPE OF THIS GUIDANCE PRINCIPLES OF CONTAINMENT 10 Control of Substances Hazardous to Health Regulations 2002 (COSHH) (as amended) 10 Specified Animal Pathogens Order 1998 (SAPO) 10 Genetically Modified Organisms (Contained Use) Regulations 2002 (GMO(CU)) (as amended) 11 Anti-terrorism, Crime and Security Act 2001 (ATCSA) 11 Animals (Scientific Procedures) Act 1986 (ASPA) 12 PART 1: HAZARD GROUP 4 PATHOGENS Viral haemorrhagic fever viruses (VHFVs) Hendra and Nipah viruses Herpesvirus simiae (B virus) Variola (smallpox) PART 2: HEALTH AND SAFETY MANAGEMENT IN CONTAINMENT LEVEL 4 FACILITIES 22 Management responsibilities 22 Risk assessment 23 Local safety policies and codes of practice 24 Staff selection, training and supervision 25 Temporary or visiting workers 27 Health surveillance 27 Record keeping 27 Emergency procedures and contingency planning 28 Incident reporting 29 PART 4: PRINCIPAL REQUIREMENTS OF CONTAINMENT LEVEL 4 LABORATORIES Generic issues Containment Level 4 laboratories PART 5: PRINCIPAL REQUIREMENTS FOR CONTAINMENT OF ANIMALS INFECTED WITH HIGH-HAZARD PATHOGENS Definition of terms Safe working with sharps Disinfection and disposal procedures Emergency procedures Protective equipment and procedures Work with simians APPENDICES 62 1: Fumigation 62 2: Maintenance 65 3: Emergency procedures 68 4: Non-microbiological hazards 73 REFERENCES AND FURTHER INFORMATION References Useful contacts Further information PART 3: GENERAL PRINCIPLES OF DESIGN AND OPERATION OF CONTAINMENT LEVEL 4 FACILITIES 31 Introduction 31 General principles of design 31 Detail design and planning 32 Commissioning and validation 34 Other issues 35

3 Preface In the UK, the principles and standards for working with high-hazard pathogens were originally laid down in the Advisory Committee on Dangerous Pathogens (ACDP) publication Categorisation of biological agents (1984; revised in 1990 and 1995). 1 This publication set new practical standards for safe working with such agents. It had the status of guidance supporting the Health and Safety at Work etc Act (HSW Act) and the Control of Substances Hazardous to Health Regulations 1988 (COSHH, now amended). The fourth edition (1995) of Categorisation of biological agents reflected the need to implement two new European Community Directives: the Biological Agents Directive (90/679/EEC), 3 which was implemented by new COSHH regulations in 1994 (revised in 2000 and 2002); 4 and the second Directive, 93/88/EEC (now replaced by 2000/54/EC) 3 which contained a European Community classification of biological agents capable of causing infection. This classification was implemented by means of an approved list of biological agents and has legal status under COSHH. The ACDP has been working to revise and update the 1995 Categorisation of biological agents guidance over the last five years. The 1995 guidance has now been replaced by three separate documents: The management, design and operation of microbiological containment laboratories HSE Books 2001, 5 which is aimed at those responsible for the management and operation of Containment Level 2 and 3 (CL2 and CL3) laboratories; Biological agents: Managing the risks in laboratories and healthcare premises HSE 2005, 6 which is aimed at the healthcare sector; and Biological agents: The principles, design and operation of Containment Level 4 facilities this document, which is aimed at high-hazard containment facilities. This ACDP guidance is aimed mainly at laboratories handling pathogens that present a risk to human health under COSHH. However, genetically modified pathogens and zoonotic pathogens will also pose a potential risk to workers. Some of these are covered by other regulatory schemes (eg the Genetically Modified Organisms (Contained Use) Regulations (GMO(CU)) and the Specified Animal Pathogens Order (SAPO)) that are discussed here only as far as they relate to human health. Further specific guidance on these is provided elsewhere The term high-hazard pathogen, for the purpose of this document, will include those organisms categorised by: EC Directive 2000/54/EC the Community classification of biological agents, implemented in the UK by means of an Approved List and known widely as ACDP Hazard Group 4 (HG4) agents; the Department for Environment, Food and Rural Affairs (DEFRA), for administering licensing under the Specified Animal Pathogens Order

4 (SAPO), for the purpose of protecting animal health from escape of organisms from laboratories. SAPO is administered by the Scottish Executive Environment and Rural Affairs Department (SEERAD) in Scotland and by the Office of the Chief Veterinary Officer at the Welsh Assembly Government in Wales. Highhazard pathogens under this scheme are those that require bio-containment at DEFRA Containment Level 4 (CL4); and the Genetically Modified Organisms (Contained Use) Regulations 2000 (as amended) (GMO(CU)). A suitable and sufficient risk assessment under these Regulations may result in a genetically modified micro-organism (GMM) being allocated appropriate containment and control measures at GM (genetically modified) Activity Class 4. 2

5 Figure 1: An overview of the relevant health and safety legislation and other guidance that should be consulted when working with biological agents in any type of microbiological containment laboratory Primary Health and Safety at Work etc Act Animal Health Act legislation Secondary regulations and Approved Codes of Practice Control of Substances Management of Health Hazardous to Health and Safety at Work Regulations Regulations general and biological agents provisions Genetically Modified Organisms (Contained Use) Regulations Specified Animal Pathogens Order General guidance Categorisation of biological agents 1 - Approved List of biological agents (www.hse.gov.uk/biosafety) Infections in the workplace to new and expectant mothers 13 A guide to the Regulations 14 Guidance Notes on containment requirements 9 (DEFRA website) Guidance on containment and control measures The management, design and operation of microbiological containment laboratories 5 Working safely with research animals, 15 including simians 16 The largescale contained use of biological agents 17 Safe working and the prevention of infection in clinical laboratories and similar facilities 18 Safe disposal of clinical waste 19 * Biotechnology: Health and safety in education 21 ** Advisory Committee on Genetic Modification (ACGM) Compendium of guidance 20 Guidance on work with specific agents Protection against bloodborne infections in the workplace 22 Transmissible spongiform encephalo pathy agents 23 The management, and control of viral haemorrhagic fevers 24 Key ACDP guidance * ** Health Services Advisory Committee guidance Education Service Advisory Committee guidance 3

6 List of abbreviations ACDP Advisory Committee on Dangerous Pathogens ACGM Advisory Committee on Genetic Modification ASPA Animals (Scientific Procedures) Act 1986 ATCSA Anti-terrorism, Crime and Security Act 2001 BMS building management system BSA biological safety advisor or other competent person appointed under the Management Regulations CCHF Crimean/Congo haemorrhagic fever CCTV closed-circuit television CDM Construction (Design and Management) Regulations 1994 CHIP Chemicals (Hazard Information and Packaging for Supply) Regulations 1994 CL Containment Level COSHH Control of Substances Hazardous to Health Regulations 2000 (as amended) DEFRA Department for Environment, Food and Rural Affairs FDA Food and Drugs Administration (USA) FFI flexible-film isolator (animals) FMEA failure modes and effects analysis GM genetically modified GMO(CU) Genetically Modified Organisms (Contained Use) Regulations 2000 (as amended) GMM genetically modified micro-organism GMO genetically modified organism HEPA high efficiency particulate air HG4 Hazard Group 4 HSE Health and Safety Executive HSW Act Health and Safety at Work etc Act 1974 HVAC heating, ventilation and air conditioning LEV local exhaust ventilation Management Regulations Management of Health and Safety at Work Regulations 1999 MHRA Medicines and Healthcare products Regulatory Agency MRI magnetic resonance imaging NaCTSO National Counter-Terrorism Security Office PPC pollution prevention control PPE personal protective equipment RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 RPE respiratory protective equipment SAPO Specified Animal Pathogens Order 1998 SEERAD Scottish Executive Environment and Rural Affairs Department SIV simian immunodeficiency virus SOP standard operating procedure UKAS United Kingdom Accreditation Service ULPA ultra low penetration air filters VHF viral haemorrhagic fever VHFV viral haemorrhagic fever viruses WEL workplace exposure limit WHO World Health Organisation 4

7 Aims of this guidance 1 This guidance aims to expand and explain the legal requirements for working with high-hazard pathogens, with a particular focus on the way in which these requirements influence the design, construction and operation of CL4 facilities. This guidance is intended for all laboratories in which high-hazard pathogens may be handled. Additional guidance covering the clinical care of patients suspected of 1, 5, 6 being infected with such pathogens can be found in other ACDP guidance. 2 In addition to providing practical guidance on how to meet the requirements of specific legislation, this document also provides advice on good practice in related aspects of design, operation and management of such facilities. 3 Details of some DEFRA CL4 containment and operating requirements for work with specified animal pathogens under SAPO licences are included throughout this guidance for comparative purposes, but the full range of DEFRA CL4 requirements are not covered. For further details of these please refer to DEFRA s website (www.defra.gov.uk). 5

8 Scope of this guidance 4 This guidance covers work in all types of laboratories where high-hazard pathogens are handled, such as in diagnostic laboratories and research facilities. It covers both deliberate propagation/concentration of the agents and work with material that contains or is likely to contain agents for which Containment Level 4 (CL4) is required. The scope of this guidance does not include work with large animals at CL4 additional guidance on this area will follow in due course. 5 For the purposes of this guidance, the following definitions apply: a laboratory is the room in which biological agents are handled; the laboratory suite is one or more laboratories, not necessarily of the same discipline or containment level, and ancillary rooms within a section or department with shared use of equipment and facilities such as media preparation, autoclaves and centrifuges; and a laboratory unit is a separate building or self-contained suite within a building containing one or more laboratories and with ancillary rooms such as airlocks, changing rooms, showers or autoclave rooms. 6 CL4 laboratories are highly specialised and those considering the design and construction of such facilities should consult widely from the outset. It would be advantageous to consult with others who have experience of such facilities including: the Health and Safety Executive (HSE); the Department for Environment Food and Rural Affairs (DEFRA); the Environment Agency; the Home Office; and the National Counter-Terrorism Security Office (NaCTSO). 7 In some respects the management, design and operational requirements of CL4 laboratories are outwardly similar to those of laboratories at CL2 and CL3. However, because the agents being handled at CL4 are more hazardous, the standards that must be achieved are considerably higher. There is, therefore, a hierarchy of control, which increases in complexity from CL2 through to CL4. An example of this hierarchy is the requirement to HEPA (high efficiency particulate air) filter input and extract air to and from the workplace; CL2 laboratories, for example, do not require any air filtration, CL3 laboratories require only the extract air to be filtered and for CL4 laboratories, both input and extract air must be filtered, with the extract air passing through two filters. Apart from the numerous differences in physical containment, a further major distinction between such laboratories is the way in which they are managed. At all types of CL4 there has to be a much more rigorous and controlled approach to management, with a correspondingly high level of work supervision. 8 It should be remembered that, at any containment level, the risk from work with biological agents is dependent on the severity of infection, the means of transmission, quantity of agents being handled and the nature and 6

9 location of the work. This needs to be addressed in local risk assessments (under COSHH and GMO(CU)). If necessary, specific control measures, in addition to the minimum required under relevant legislation, should be put in place to ensure that the work is carried out safely. 9 Table 1 illustrates the number of laboratory-acquired HG4 infections reported worldwide during the past 30 years or so. The table clearly shows that laboratoryacquired infections do occur despite stringent laboratory controls. The figures given are based on documented cases of severe and frequently fatal naturally occurring human infections and aerosol-transmitted laboratory infections. It should be noted, however, that these viruses can cause severe human disease that can spread to the community and there is no effective prophylaxis or treatment available. Although naturally occurring outbreaks of these viruses are rare, they can have a devastating effect. The recent Marburg outbreak in Angola (2005) had a 90% fatality rate in the 252 people infected. Table 1: An illustration of the number of cases of laboratory-acquired infection with HG4 agents worldwide over the past 30 years Laboratory or laboratory animal associated human infections Virus Cases Fatalities Source(s) and route of infection Lassa 2 1 Aerosol processing infected rodent tissue Junin 21 1 Aerosol processing infected rodent tissue Sabia 3 1 Aerosol centrifuging infected tissue culture Crimean/Congo haemorrhagic fever 8 1 Aerosol processing infected rodent tissue Machupo 1 1 Aerosol processing infected rodent tissue Marburg 15 1 Direct contact with infected monkey tissue Ebola 1 0 Direct through needle stick Herpesvirus B ~50 29 Direct contact with monkeys Liaison with other government bodies 10 In addition to the health and safety requirements covered in this guidance, a number of other agencies have mandatory requirements, which will influence the design process. These may include the agencies listed in paragraphs Department for Environment, Food and Rural Affairs (DEFRA) 11 In England and Wales, DEFRA forms part of the joint Competent Authority (with HSE and the Secretary of State) to oversee the GMO(CU) Regulations. DEFRA also administers the Specified Animal Pathogens Order in England. DEFRA should be consulted throughout the design stage to ensure compliance with any mandatory control measures under these regulations. The Specified Animal Pathogens Order is discussed in further detail in paragraphs

10 Health and Safety Executive (HSE) 12 HSE forms part of the Competent Authority for England and Wales (along with DEFRA and the Secretary of State) to oversee the GMO(CU) Regulations. These Regulations specify mandatory containment controls for high-hazard laboratories and HSE provides a key regulatory function through notifications, interventions and inspections. Scottish Executive Environment and Rural Affairs Department (SEERAD) 13 In Scotland, the Specified Animals Pathogens Order is administered by the Scottish Executive Environment and Rural Affairs Department (SEERAD). SEERAD aims to promote rural development and ensure that the needs and interests of rural Scotland are reflected in all of the Executive s policies and priorities. 14 SEERAD is responsible for advising ministers on policy relating to agriculture, rural development, food, the environment and fisheries, and for ensuring the implementation of those policies in Scotland. National Assembly for Wales 15 In Wales, the Office of the Chief Veterinary Officer at the Welsh Assembly Government is responsible for administering SAPO. The Home Office 16 If living animals are to be tested and experimented upon, then the Animals (Scientific Procedures) Division and the Animals (Scientific Procedures) Inspectorate will need to be involved in discussions. The Inspectorate has the responsibility for inspecting those facilities where work with animals is carried out and will be seeking to ensure that facilities conform to the code of practice for the housing and care of animals used in scientific procedures. Consequently, designers of the premises will need to ensure that animal facilities conform to defined standards for animal welfare. For example: the animal house should be designed, sited and constructed to provide a suitable environment, including any special requirement for exercise or social contact for the species to be housed; temperatures in animal rooms will need to be carefully controlled and continuously monitored. The equipment, insulation and design of the building should be such as to ensure that the correct temperature can be maintained in both winter and summer; extreme variations in relative humidity can have adverse effects on the wellbeing of animals. Prolonged periods below 40% or above 70% should be avoided; design should take into account the fact that building maintenance may disturb animals and disrupt experiments; services should be installed to be accessible from outside and with fittings that can be removed by staff for maintenance and repair; the air distribution system should deliver as even a proportion of air to each cage or animal as possible while avoiding draughts. This is an area of particular importance, especially as differential air pressures will be used throughout the facility. The number of air changes per hour required by Home Office regulations is different for various animal species. Please refer to Home Office guidance (see paragraph 17) for further details. 17 Much of the information relating to animal welfare is provided in the Home Office document Code of Practice for the housing and care of animals used in scientific procedures. 25 8

11 The Environment Agency 18 The Environment Agency has responsibility for enforcing the laws covering the risks to the environment from hazardous waste. It is important to inform the agency that plans are being progressed to build a CL4 facility, the most appropriate way of doing this will be via the local area office. 19 The special waste regulations are currently being superseded by the Hazardous Waste Regulations Under the new Regulations, any waste requiring specialist treatment or disposal (including incineration) due to the infection risk posed, irrespective of the level and type of infection, will be considered hazardous infectious waste. 20 In summary, the new Regulations require producers to: register with the Environment Agency; segregate more categories of hazardous waste from non-hazardous waste; increase the amount of information provided for consignment; keep consignment notes (and any associated paperwork) for three years. 21 The Environment Agency has produced Technical Guidance WM2 27 on the Hazardous Waste Regulations This guidance is available from the Environment Agency s website (www.environment-agency.gov.uk). Local authorities 22 The main consideration for the local authority relates to provision of adequate planning and public consent. The design team may want to consider the merits of local public consultation. A remit of this committee would be to seek out and provide accurate information to the community to foster a greater understanding of the activities that will be undertaken in the building. Fire authorities 23 Pertinent information can be obtained from the local fire brigade and the British Fire Service. 28 The planning team would need to ensure that the design process identified what was required to prevent fire in the workplace. Furthermore, sufficient information about the layout of the building and what the building was used for would have to be provided to firefighters to enable them to carry out their duties safely. In the event of a fire at a high-hazard facility, it is highly unlikely that fire service personnel would readily enter the building without first being appraised of the situation and the hazards involved. Careful consideration should be given in the design of these facilities for the inclusion of appropriate fire control/suppression systems (automatic shut-down systems, inert suppression systems) or detailed thought into the best policy to adopt, such as a burn-down policy, should be taken in consultation with the fire service and local authority. 9

12 Principles of containment 24 The term containment describes the way in which high-hazard pathogens are managed in the laboratory environment to prevent exposure of laboratory workers, other workers and people and animals in the outside environment to the agent(s) in question. This can be achieved in a number of ways: primary containment: ie protection of the worker and the immediate environment can be achieved through a combination of good microbiological practices or techniques and the use of appropriate primary containment devices, eg Class III microbiological safety cabinets; secondary containment: ie protection of people and the environment outside the laboratory can be achieved by a combination of laboratory design and operating procedures, eg access restriction, air handling and safe disposal of waste. 25 In addition to the more general means of preventing or controlling exposure to high-hazard agents, there is also a requirement for the use of certain minimum containment measures for laboratories handling particular groups of biological agents. CL4 must be used if an assessment indicates to an employer that such a containment level is necessary, even if there is no intention to deliberately propagate and concentrate high-hazard agents. Control of Substances Hazardous to Health Regulations 2002 (COSHH) (as amended) 4 26 The ACDP classification of biological agents was revised in 1994 as a result of the implementation of European Directive 2000/54/EC, which changed the status of the classification list into law, now being an Approved List made under the Health and Safety at Work etc Act COSHH was revised in 2002 to move the general requirements for work with biological agents into the main body of the COSHH Regulations. 27 COSHH classifies biological agents into four hazard groups based on their ability to infect and cause harm to humans. COSHH does not consider environmental risks. 28 If employers cannot prevent exposure to a biological agent they should take steps to ensure that it is adequately controlled. A risk assessment should be performed and appropriate control measures selected to adequately control the risks. For Hazard Group 4 (HG4) agents, the controls from Part II of Schedule 3 should be applied as a minimum. Specified Animal Pathogens Order 1998 (SAPO) 8 29 The Specified Animal Pathogens Order 1998 prohibits any person from having in their possession any specified animal pathogen listed in Part I of the Schedule to 10

13 the Order, or any carrier in which they know such a pathogen is present, except under licence. It also prohibits the introduction into any animal or bird of any pathogen listed in the Schedule to the Order (Parts I and II) except under licence. 30 The purpose of SAPO is to prevent the introduction and spread of animal pathogens that cause serious exotic diseases in livestock and poultry and economic loss to the British livestock and poultry industries. Containment and operating requirements imposed under SAPO are therefore concerned with preventing the escape of pathogens from the laboratory and not with the protection of laboratory workers or other people. The possession of a licence under SAPO does not in any way limit the obligations placed upon employers and employees by the Health and Safety at Work etc Act 1974 or specific legislation made under the Act. Where work with specified animal pathogens is being undertaken, both DEFRA requirements and the relevant requirements of health and safety legislation apply. 31 Specified animal pathogens are classified into three main categories by DEFRA: DEFRA Group 2, DEFRA Group 3 and DEFRA Group 4 Group 4 requiring the highest level of containment. This guidance is also intended for laboratories working with Group 4 specified animal pathogens that can cause harm to humans, for which the relevant COSHH and DEFRA containment requirements will both apply. Genetically Modified Organisms (Contained Use) Regulations 2000 (GMO(CU)) (as amended) 7 32 Contained use is where control measures are used to limit contact between GMO s and humans and the environment, to provide a high level of safety. In practice, this involves work in laboratories, animal houses, plant growth facilities (including growth rooms in buildings and suitable glasshouses) and large-scale production facilities on industrial sites. 33 The primary piece of legislation that applies to the use of genetically modified organisms in the workplace is the Genetically Modified Organisms (Contained Use) Regulations 2000 (GMO(CU)), as amended in 2002 and The GMO(CU) Regulations provide for human health and safety and environmental protection from genetically modified micro-organisms in contained use. The key requirement of the GMO(CU) Regulations is to assess the risks of all activities and to classify each activity based on the control and containment measures required. 35 The main requirement of GMO(CU) is to assess all activities for the risk to human health and the environment. Containment is based on a risk assessment and selection of appropriate control measures from Part II, Schedule 3 of COSHH. All Class 4 activities require notification of premises and consent from the Competent Authority before work can begin. Anti-terrorism, Crime and Security Act 2001 (ATCSA) Part 7 of the Anti-terrorism, Crime and Security Act 2001 contains further legal requirements to ensure that the storage and use of dangerous pathogens and toxins listed in Schedule 5 of the Act is as secure as practicable. This is achieved by effective levels of physical security and by limiting access to those authorised to work with Schedule 5 agents. 11

14 37 All facilities handling or storing Schedule 5 agents must satisfy Home Office requirements, whether they are being developed as part of a refurbishment or a complete new-build. All current CL4 premises must comply with these requirements. Organisations considering new or upgraded CL4 premises should contact the National Counter-Terrorism Security Office (NACTSO) at the earliest stage possible for specialist advice on how to comply with current legislation (Tel: ; or in writing to NACTSO, PO Box 849, London SW1P 1XD). 38 The security of each individual site will need to be approached according to its own unique features. It is strongly recommended that advice is sought at the earliest possible stage from NaCTSO, who will assess security measures in consultation with the site owners/managers and their own experts. To facilitate this process, the project manager should contact NaCTSO with the following information before the design of the facility: name and contact details of the project manager/point of contact; full location details of the proposed site; nature of the build (new facility or refurbishment); proposed timescales for the project. 39 The level of physical security required for CL4 facilities includes a robust perimeter fence (or equivalent), 24-hour manned security and multiple layers of access control. Further details on physical security requirements can be found in the Home Office publications Security standards for laboratories 30 and Personnel security measures for laboratories, 31 which are available on request from NaCTSO (Tel: ). Animals (Scientific Procedures) Act 1986 (ASPA) The Animals (Scientific Procedures) Act 1986, administered by the Home Office, imposes clear responsibilities on people with specific roles in relation to the care and use of animals in laboratories. (These are elaborated further in Guidance on the operation of the Animals (Scientific Procedures) Act 1986.) 33 All animalhandling procedures should only be carried out under the authority of a Project Licence and a Personal Licence issued by the Home Office. 41 Table 2 sets out the minimum containment requirements of the COSHH, SAPO and GMO(CU) Regulations for work in CL4 laboratories. (Under GMO(CU), an assessment may indicate that not all of the containment controls need to be applied. Consent from the Competent Authority is required before making any changes to the requirements in this table.) 12

15 Table 2: Containment measures for CL4 laboratories under appropriate legislation Containment measures COSHH SAPO GMO(CU)* The workplace is to be Yes Yes Yes separated from any other activities in the same building Input air and extract air to the Yes, on input and Yes, single on input and Yes, extra requirements workplace are to be filtered double on extract air double on extract air for viruses using HEPA or equivalent Access is to be restricted Yes, via airlock key Yes, restricted and entry Yes, via airlock key to authorised people only procedure through an airlock, clean/ dirty area. Shower on exit The workplace is to be Yes Yes Yes, sealable for sealable to permit disinfection fumigation Specified disinfection procedure Yes Yes Yes The workplace is to be Yes Yes, pressure to be Yes maintained at air pressure maintained at not less negative to atmosphere than -75 Pa Efficient vector control, Yes Yes, and proofed Yes eg rodents and insects against entry or exit of animals and insects Surfaces impervious to Yes, for bench, floor, Yes, for working surfaces, Yes, for bench, floor, walls water and easy to clean walls and ceiling walls and ceiling and ceiling Surfaces resistant to acids, Yes, for bench, floor, Yes, for working surfaces, Yes, for bench, floor, alkalis, solvents, disinfectants walls and ceiling walls and ceiling walls and ceiling Safe storage of a Yes, secure storage Yes, secure storage Yes, secure storage biological agent in the laboratory suite. Inventory to be maintained An observation window, or Yes Yes Yes alternative, is to be present, so that occupants can be seen A laboratory is to contain its own equipment Yes Yes Yes Infected material, including Yes Yes Class III cabinet required any animal, is to be handled in a safety cabinet or isolator or other suitable containment Incinerator for the disposal of Yes, on site Yes, or some other Yes, on site animal carcasses validated means of pathogen inactivation and safe carcass disposal 13

16 Table 2: Containment measures for CL4 laboratories under appropriate legislation (continued) Containment measures COSHH SAPO GMO(CU)* Treatment of liquid and solid wastes All waste should be made safe or safe to handle before leaving the laboratory All wastes to be sterilised by a procedure known to inactivate the pathogen(s). For solids this requires autoclaving followed by incineration Inactivation by validated means Laboratory security Laboratory and animal rooms to be kept secure and locked. Intruder alarm system to be fitted * GMO(CU) Regulations specify additional control measures for work with genetically modified micro-organisms in animal units, plant growth facilities and for large-scale work. 14

17 Part 1: Hazard Group 4 pathogens Table 3: Hazard Group 4 viruses 1 Haemorrhagic fever viruses 42 This section covers both ACDP Hazard Group 4 agents and DEFRA Group 4 zoonotic pathogens. 43 The Advisory Committee on Dangerous Pathogens has specified that CL4 must be used for all work involving the 18 agents listed in Table 3. These agents are all viruses and can cause severe, life-threatening disease. Most of these viruses are endemic in many parts of the world, notably Africa, South America and some rural parts of the Middle East. 44 The UK does not contain natural reservoirs of these viruses and environmental conditions are unlikely to support an epidemic spread of these agents. It is more likely that infections with these agents will be acquired abroad, from a laboratory infection or from an imported animal. Virus Country first recognised Date Natural host Mortality rate (humans) Arenaviridae Old World Arenaviruses Lassa virus Nigeria 1969 Rodent 15% Guanarito Venezuela 1989 Rodent 25% Junin Argentina 1957 Rodent 15-30% Machupo Bolivia 1962 Rodent 25% Sabia Brazil 1990 Rodent 33% Bunyaviridae Crimean/Congo Crimea 1944 Hyalomma 10-50% Nairovirus haemorrhagic ticks fever Democratic Republic of Congo 1969 Filoviridae Ebola virus Ebola Reston USA 1989 Unknown Sub-clinical Ebola Sienna Italy 1992 Unknown Non-infectious? Ebola Sudan Sudan 1976 Unknown 50% Ebola Zaire Democratic Republic of Congo 1976 Unknown 90% Marburg Marburg Germany and Yugoslavia 1967 Unknown 23-25% 15

18 Table 3: Hazard Group 4 viruses (continued) 2 Other viruses Virus Country first recognised Date Natural host Mortality rate (humans) Herpesviridae Herpes simiae (B virus) Worldwide 1932 Primate 80% Paramyxoviridae Nipah Malaysia 1999 Fruit bat 2 out of 3 Hendra Australia 1994 Fruit bat 60% Poxviridae Variola (major Worldwide now Humans 30% (major), 1% (minor) and minor) eradicated, last natural case Somalia 1977 Flaviviridae Kyasanur Forest Disease India 1957 Tick 10% Omsk Russia 1990 Muskrats Variable Russian Spring Russia 1937 Tick 50% Summer Encephalitis Viral haemorrhagic fever viruses (VHFVs) 45 Viral haemorrhagic fevers (VHFs) are a group of illnesses caused by several distinct families of viruses. The term is used to describe a severe, multi-organ syndrome in which the overall vascular system is damaged and the body s ability to regulate itself is impaired. These symptoms are often accompanied by bleeding. While some types of VHFV can cause relatively mild illness, many of these viruses cause severe, life-threatening disease. 46 Humans are not the natural reservoir for any of these viruses. Humans become infected when they come into contact with infected hosts. The main reservoirs of these viruses are rodents and insects. However, the host for some of these viruses is still unknown. Humans can transmit the viruses to other humans under specific circumstances (person-to-person transmission). 47 Viruses associated with haemorrhagic fever are RNA viruses from four distinct virus families: arenaviruses, filoviruses, bunyaviruses and flaviviruses. They all have a RNA genome, are enveloped and are transmitted via animal or insect hosts. Viral survival is dependent on the availability of their natural host and as such they are restricted to where their host species live. 48 There is a risk of secondary infection with these diseases, particularly among hospital and laboratory staff, due to possible inoculation or contamination of broken skin or mucous membranes by infected blood or body fluids. Between 1997 and 2001, there were only eight notified cases of suspected VHF (only three of which were confirmed) in England and Wales. When cases of VHF do occur in the UK, they tend to involve personnel involved in patient care, such as general practitioners, community nurses, accident and emergency staff, diagnostic staff, ambulance workers, nurses, mortuary staff and funeral workers. Further guidance for these workers can be found in ACDP publication The management and control of viral haemorrhagic fevers

19 Arenaviruses 49 Arenaviruses are generally associated with rodent-transmitted disease in humans and a number of arenaviruses can cause haemorrhagic disease. The first of these to be isolated and identified was Junin virus, isolated in This virus caused Argentine haemorrhagic fever in a limited agricultural area of the pampas in Argentina. Several years later, in 1963, in the remote savannahs of the Beni province of Bolivia, Machupo virus was isolated. Lassa virus was the next member associated with an outbreak of human illness in Africa in This virus has proven to be endemic in West Africa, where there have been many epidemics of varying size. More recently, two further viruses have been isolated: Guanarito virus (responsible for 15 cases of haemorrhagic fever in the central plains of Venezuela in 1989) and Sabia virus (isolated in Brazil in 1990). Filoviruses 50 Filoviruses can cause severe haemorrhagic fever in humans and non-human primates. So far, only two members of this virus family have been identified: Marburg virus and Ebola virus. Marburg was first recognised in 1967 when a number of laboratory workers in Germany and Yugoslavia, handling tissue from green monkeys, developed an acute haemorrhagic fever. A recent outbreak of Marburg virus in Angola (2005) killed over 200 people. The second member of the filovirus genus, Ebola, was first discovered during a simultaneous outbreak of a haemorrhagic infection in the Democratic Republic of Congo (DRC, formerly Zaire) and the Sudan (1976). 51 In 1989 a new Ebola subtype was identified from imported cynomolgus macaques during an outbreak in a primate quarantine facility in the USA in There have been a number of sporadic Ebola-related outbreaks of VHF in the Gabon, Cote d Ivoire, Sudan and DRC from Four distinct species of Ebola virus are now known: Ivory Coast, Sudan, Zaire and Reston. Ebola Reston is the only filovirus that does not cause disease in humans. Bunyaviruses 53 Crimean/Congo haemorrhagic fever virus (CCHF) is a tick-borne virus first discovered in the Crimea in The virus was more recently recognised and isolated following an outbreak in the DRC in CCHF is carried by the Hyalomma tick, which is widespread throughout Africa, Asia, the Middle East and southern/eastern Europe. Mode of transmission 54 All HG4 VHF viruses are transmitted through direct contact with virus-infected body fluids such as blood, saliva, vomit, stools and possibly sweat. Person-toperson transmission of arenaviruses is very rare, although there have been reports of Lassa fever being transmitted this way. Cross infection with partially sterilised needles is associated with a high infection risk and a high fatality rate. 55 There is no evidence of VHFVs being transmitted through close personal contact with non-febrile, non-symptomatic, infected individuals during either incubation or convalescence periods. Previous epidemics in Africa have resulted largely from secondary transmission to healthcare workers and close family contacts caring for infected individuals. The reuse of needles and syringes, inadequate barrier techniques, and unhygienic practices are the major sources of hospital-acquired infections among staff and patients. Close contact with the body or body fluids of the dead in customary preparation for burial is also a recognised source of infection. 56 These viruses are not airborne, but they may be transmitted by aerosols of body fluids from infected patients if these aerosols come into contact with mucous membranes. 17

20 57 Most CCHF infections occur through tick bites, but airborne infections have occurred in both hospital and laboratory environments, and in the livestock industry (agricultural workers, slaughterhouse workers and veterinarians). Infectious dose 58 The infectious dose of all VHF infections is unknown. Incubation period 59 The incubation period varies between 1 and 21 days. The infectivity period depends on viral type and the mode of infection. Period of communicability 60 Patients with clinical symptoms are considered to be infectious. There are reports of late transmission events (92 days for Marburg). Lassa fever virus can be shed in urine for several weeks following infection and carried in semen for several months after the illness has resolved. Reservoirs of infection 61 Arenaviruses are divided into two groups: the New World or Tacaribe complex and the Old World or Lassa complex. Lassa-complex viruses are associated with the Old World rats and mice (family Muridae, subfamily Murinae, especially in West Africa (Mastomys coucha and M. natalensis)). The Tarcaribe-complex viruses are generally associated with the New World rats and mice (family Muridae, subfamily Sigmodontinae). 62 All of the rodent reservoirs experience silent, lifelong viraemia with high titre viruria, which is the primary source of environmental contamination with these viruses. 63 Non-human primates were associated with the initial outbreaks of Marburg disease (Cercopithecus spp.) and more recently filoviruses related to Ebola were associated with Macaca spp. and chimpanzees. 64 CCHF has been recognised in a wide range of domestic and wild animals. Ostriches, for example, are extremely susceptible and show high prevalence of infection in endemic areas. 65 A number of tick species are capable of becoming infected with CCHF virus, the most efficient being members of the Hyalomma genus where transmission from female to offspring via eggs has been demonstrated. 66 The most important source for the acquisition of the CCHF virus is believed to infect small vertebrates on which the immature Hyalomma ticks feed. Tick transmissions to large vertebrates such as domestic livestock (cattle, sheep and goats) are very common. Laboratory hazards 67 Work with or exposure to rodents, non-human primates or vectors naturally or experimentally infected with these agents represents a potential source of human infection. 68 The infectious agents may be present in the blood, urine, respiratory and throat secretions, semen and tissue from human and animal hosts and in rodents and non-human primates. 69 Health workers in endemic and non-endemic areas should be particularly aware of the illnesses, since there may be a high risk of hospital-acquired infection. 18

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